Gayathri Narayanasamy - IOSR Journals 9/Version-2...Gayathri Narayanasamy I. Introduction Psychiatric oncology is the field of medicine concerned with frequent mental and affective

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e-ISSN: 2279-0853, p-ISSN: 2279-0861.Volume 15, Issue 9 Ver. II (September. 2016), PP 50-77

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DOI: 10.9790/0853-1509025077 www.iosrjournals.org 50 | Page

A study of psychiatric comparability in subjects with malignancy

Gayathri Narayanasamy

I. Introduction Psychiatric oncology is the field of medicine concerned with frequent mental and affective problems

that we come across in sufferers of cancer and their loved ones. It encompasses the study of pain due to

malignancy and its palliative care, mental illness screening, quality of life, communication skills for physicians

in handling difficult questions and breaking bad news, and counselling. It is also concerned with management of

staff stress and burnout among health care providers (Chaturvedi, 2012).

Depression and anxiety occur in a substantial proportion (15-25%) of cancer patients (Agarwal, 2010).

Because of methodological issues and difficulties in distinguishing depressive symptomatology from that of

malignancy, the real frequency of depressive disorders in sufferers of malignancy may be much higher (Pasquini

& Biondi, 2007). In spite of the lack of clarity of the contributory link between malignancy and depressive

disorders, a relationship has been often cited (Kissane, 2009).

Depression comprises 4.4% of the worldwide illness burden taken as a whole, just like IHD and

diarrhoea (WHO 2000). Disability adjusted life years for depressive disorder is going to be more than for

malignancy or retroviral disease (Ustun, 1999). 15% of recently diagnosed cancer patients meet criteria for

MDD (Grassi & Rosti, 1999). Sharpe (2004) reported 8% prevalence of MDD in cancer patients, most of them

with inactive disease. Prieto (2005) reported 9% prevalence in inpatients with haematological cancers. Coyne

(2004) reported same prevalence in breast cancer patients. Ell (2005) found 24% prevalence among low-income

women with cancer. Okamura (2002) found 22% prevalence of MDD at time of first recurrence of carcinoma of

breast. Depression and anxiety was found to be 33% prevalent at the time of diagnosis, 15% at 1 year after

diagnosis, and 45% following recurrence (Burgess, 2005).

Maximum number of studies has been done in breast cancer patients (Prieto, 2005, Zabora, 1997,

Kadan-Lottick, 2005, Korfage, 2006). Symptoms of depression in women getting treatment for early stage

breast carcinoma are not associated with objective variables related to cancer (Bardwell, 2006). Ashbury (2003)

reported that failing to diagnose Major Depressive Disorder (MDD) in sufferers of cancer

leads to:

1. Decline in their quality of life

2. Longer duration of stay in hospital

3. Non-compliance with treatment plan

The possible predictors of anxiety and depressive disorders in patients with cancer are:

1. Demographic factors - age, sex, education, employment, income, and marital status, proximity to family,

patient’s social network, life stresses and coping.

2. Illness-related factors - type of cancer, time since diagnosis, cancer stage and grade, and presence of

symptoms, effects of treatment, attitudes and beliefs about cancer, comorbid medical illness.

Literature suggests that the impact of malignancy on depression is buffered by social support so that

depression risk is lesser in those with good social support. (Mathieson, 1996)

There is not much literature regarding the predictors of depression and anxiety in cancer patients in

India. We studied the demographic and illness factors related to depression and anxiety in this population. We

hope that this might be helpful in developing better informed interventions for ameliorating the quality of life of

sufferers of malignancy who are at danger of developing anxiety and/or depression.

II. Review Of Literature Cancer is a very traumatic experience involving the following issues which predispose to

depression and/or anxiety:

i. Encountering the likelihood of mortality

ii. Body image and self-esteem alterations

iii. Apprehension of invasive procedures and pain

iv. Familial, occupational and societal role changes

v. Interruption of life plans

All these are significant matters to be handled. Also, the course of the illness and treatment adherence

may be affected by depression. The cost and frequency, the harm caused, and the uncertainty with regard to



diagnosis and treatment due to depression among sufferers of cancer make it a main concern for scientific

enquiry (Pasquini and Biondi, 2007).

Strategies employed to cope; feelings of loss, conscious efforts at adapting and changeover affect

clinical manifestations of depression in cancer patients (Brennan, 2001). Anxiety and depression are often

undetected and hence left unmanaged in sufferers of malignancy, ensuing in a major harmful impact on quality

of life and outcome of illness (Berard, 2001).

Physicians are prone to underestimate symptoms suggestive of depression in patients with malignancy.

If physicians are trained to look out for the more dependable cognitive symptoms, such as lack of pleasure

seeking, remorse, suicidality and despair, their assessment may be improved. It would be useful to employ

screening instruments and brief follow-up interviews to find out sufferers with depression (Passik, 1998).

Making a diagnosis of depressive disorder in an advanced malignancy is made intricate by the actuality

that a lot of symptoms of malignancy have common characteristics with depressive somatic symptomatology.

Approaches to somatic symptoms (Bailey, 2005):-

1. Inclusive model- Somatic symptoms are taken into account regardless of cause, while diagnosing MDD in

cancer patients.

2. Substitution model (Endicott, 1984) - Somatic symptoms are substituted by non-somatic symptoms of

depression.

3. Exclusive model- Somatic symptoms are disregarded as diagnostic criteria.

For evaluating depressive disorder in sufferers of advanced malignancy, Endicott prefers the

substitution of somatic symptoms with physiological symptoms:

Somatic/physical symptoms:

1. Weight/appetite change

2. Insomnia

3. Loss of energy/fatigue

4. Decreased concentration

Psychological symptoms which are substituted:

1. Sad demeanour, tearfulness

2. Alogia, asociality

3. Negative outlook on life, lamenting, self-pity

4. Restriction of affect, reduced reactivity (Endicott J, 1984).

The somatic symptoms are probably responsible for the alterations in the Beck Depression Inventory in

cancer patients than the affective symptoms (Wedding, 2007).

The centuries-old stigma attached to malignancy did not allow the diagnoses to be told to the patients.

This led to the avoidance of any chance to come to know of the ways in which cancer sufferers coped with their

disease. Also, a second and similarly long-held stigma attached to mental disorder has been another obstacle and

this has prevented sufferers from being able to recognize their emotional struggles and to go for counselling.

The progress of psychological oncology has been slow because of this ―double stigma‖ (Holland, 2003).



III. Prevalence In a study, 24% of a group of sufferers of malignancy had severe depression, 18% had moderate

depression. Depressive symptoms not meeting criteria for major depression were present in another 14%.

Important predictors were greater degree of physical debility, other negative life events and poor social support

(Bukberg, 1994).

Estimated frequency of depressive disorder in various subgroups of sufferers of malignancy, in a

systematic review, was as follows: outpatients- 5% to 16%; admitted patients- 4 to 14%; mixed sample

including both patients receiving treatment on outpatient basis as well as those admitted- 4 to 11% and palliative

care- 7 to 49%. Lower prevalence was found by studies which employed specialist interviewers (clinical

psychologists and psychiatrists) (Walker, 2013).

In a study on women with newly diagnosed carcinoma breast, the following findings were reported.

Clinically significant distress was present in 41% of the subjects. Major depression was present in 11% (60% of

whom had moderately severe to severe depression) and posttraumatic stress disorder was present in 10%

subjects. These emotional symptoms had a marked impact on the functioning of the patients. Though 56% of the

depressed patients were already on psychotropic medications, they still did not remit. (Hegel, 2006)

Psychiatric referral patterns at two Japanese cancer hospitals showed that the most commonly referred

were patients with lung cancer (19%), followed by carcinoma breast (13%) and malignancy of the head and

neck (10%). More than 50% of the sufferers had cancer recurrence or metastasis, pain was present in 60%. The

most frequent reasons for psychiatric referral were assessment by mental health professional (35%), insomnia

(19%), fear/anxiety (18%), and depressive disorders (18%). Adjustment disorder (34%), acute confusional state

(17%) and major depressive disorder (14%) were the most common psychiatric diagnoses. (Akechi, 2001)

Adjustment disorder or major depression was seen in about 17% of the subjects in one study among

recently found out sufferers of malignancy of head and neck. Nicotine dependence was present in about 33%.

Psychological distress had significant association with stage of cancer and living alone. (Kugaya, 2000)

DIFFERING VIEW: A study looked for anxiety and depression in patients with prostate or other

urogenital cancers. The highest anxiety mean scores were recorded at the start of the hospital stay (i.e. in stage

T1). From stage T2 to T4, the prevalence of anxiety was similar to that of the general population, and even less

than that found in cardiac patients. Lower prevalence of depression was found compared to the general

population. Higher psychological distress was found in those who were younger, and in those who were

receiving radio- or chemotherapy. Based on their findings, the authors concluded that professional psychiatric

help was not required by most prostate cancer patients and that some patients may benefit from such help,

especially at the beginning of the hospital stay. (Hinz, 2009)

Adjustment disorder with depressed mood or depressive disorder is found in about 25% of hospitalized

cancer patients. Important predictors are mood disorder or alcoholism in the past, cancer stage, presence of pain,

medications which produce depressive symptoms, concurrent illnesses which lead to depressive symptoms

(Massie MJ, 1990).

Another study reported that emotional distress that was clinically noteworthy (Hospital Anxiety and

Depression score ≥15) was present in about 1/4th of the study sample of 3071 patients. Important determinants

were age less than 65 yrs, female gender, and type of cancer and extent of disease (Strong, 2007).

A study done in a tertiary care hospital among gynaecological oncology outpatients found that nearly

26% had depression and 17% had anxiety (Mendonsa and Appaya, 2010).

In an outpatient oncology setting, about 14% were found to have depression. They found that the

existing health care system had managed to identify and treat only 14% of the interviewed depressed patients

and they highlighted the need for suitable screening tools (Berard, 1998).

It is hard to assess mood disorder when a cancer sufferer is faced with recurring threats to existence,

receiving treatments for malignancy, has fatigue or aches. Many studies since the 1960s have found the

prevalence of depression between 0-38% and that of depression spectrum syndromes as being 0-58%. This wide

variance is due to different conceptualisations of depression, different defining criteria for depression, different

methodological approaches in measuring depression and different populations being studied. Cancers with

highest depression prevalence were upper digestive tract (22-57%), pancreas (33-50%), mammary (1.5-46%)

and pulmonary (11-44%) (Massie, 2004).

In another study, 40% of carcinoma lung sufferers had anxiety and 25% were depressed, and this was

found to be equal among hospitalized patients as well as those attending the outpatient clinic. (Du-Quiton,

2010).

Effect of depression on cancer

Most studied cancers in this regard are malignant melanoma, CA lung, and renal carcinoma

and CA breast. The mortality risk is raised when depressive symptoms co-occur with malignancy (Onitilo,



2006). The 1 year and 3 year case fatality rate was increased significantly by the occurrence of depression in

sufferers of hematologic malignancy following stem cell transplantation (Prieto, 2005).

In sufferers of lung malignancy, reduced survival times are foretold by emotional distress and

depressive coping style (Faller, 1999).

How depression affects cancer prognosis:

1. As a direct neuroimmunologic consequence

2. Depression may lead to poorer compliance to the treatment given for cancer

The Minnesota Multiphasic Personality Inventory (MMPI) clearly differentiates the psychological

distinction among the two extreme set of cancer sufferers- those with rapidly progressing disease and those with

a far longer expectancy (Blumberg, 1954).

Psychosocial factors like social support, stress, emotional expression, depression and personality have

been found to influence the incidence and progression of cancer. This relationship has been proposed to be

mediated by mechanisms such as changes in diet, exercise, and circadian rhythms; differences in treatment

received; and endocrinologic and neuroimmunologic physiological changes (Spiegel and Kato, 1996).

There is a profound stimulating effect of stress on the growth rate of an established cancer (Blumberg,

1954). The cell-mediated immunity, which protects an individual against cancer, may be affected by depression.

The impaired host defense mechanisms may pave the way for neoplastic cells to proliferate and spread out of

control. Increased IL-6 plasma levels were associated with MDD in cancer patients (Musselman, 2001; Jehn,

2006). Social support is protective against IL-6 elevation in patients with advanced malignancy of the ovary &

IL-6 appears to be a marker of health related quality of life (Constanzo, 2005). Therefore, IL-6 is a biomarker of

depressive disorder in sufferers of malignancy.

In case of severe depressive disorder preceding malignancy, the depressive illness may present an

additional risk (Kronfol, 1982; Linn, 1982).

The course of cancer and treatment compliance is also severely impacted upon by depressive disorders

(Pasquini and Biondi, 2007).

Depression And Cancer Mortality: Studies have found that the diagnosis of depression and more severity

predicted increased mortality in cancer patients (Pinquart and Duberstein, 2010). Mental anguish was a

forerunner of death due to malignancy, particularly in pulmonary malignancy (Hamer, 2009).

In one study among patients with advanced non-small cell lung cancer (NSCLC), the median survival

time in the depressed group was significantly shorter than that of the non-depressed group. The mortality risk in

the group with depression was twice that seen in the group without depression. The result shows that depression

at the starting stage of cancer therapy predicts decreased survival in sufferers of advanced non-small cell lung

cancer (Chen, 2011).

Depressive disorder foretold reduced survival in sufferers of recently detected non-small cell lung

cancer in metastatic phase. In spite of the fact that early palliative care (EPC) was linked with more reduction in

depressive symptomatology at 12 weeks, the study findings did not support the premise that the survival benefit

which was seen to be due to EPC was a consequence of the treatment of depression (Pirl, 2012).

DISSENTERS: A nationwide Danish cohort study, carried out over a period of 24 years, found that their

findings did not support the premise that depressive disorder separately raises cancer possibility, but they

emphasized the detrimental effects of depressive symptomatology on aspects of day-to-day life (Dalton, 2002).

Another study found no evidence of an increased risk of cancer in patients with depression and/or anxiety for

over a decade (Friedman, 1990).

Depressive disorder is linked to inferior quality of life, suppression of immune reaction and reduced

survival in sufferers of malignancy (Williams and Dale, 2006).

Relationship of various parameters to depression and anxiety in cancer

Role of aging:

Growing old was associated with decreased anguish, decreased apprehension, and improved

psychological quality of life. At the same time, growing old was linked to increased depression in these sufferers

of malignancy (Nelson, 2009).

The frequency of anxiety and depression in sufferers of malignancy was notably influenced by age upto

40 years (Jadoon, 2010).

Depression frequently manifests in a different way both in sufferers of malignancy as well as in old

age. Hence a tailored and customized way of evaluation should be used when making a diagnosis and managing

these persons (Weinberger, 2009).



Compared to any other psychopathological variable studied; disease has a greater independent role

(Fafouti, 2010).

In a study, the only variables found to affect distress and depression were higher socioeconomic status

and female gender respectively (Pandey, 2006).

Effect of being aware of diagnosis:

Psychological distress was higher in those who knew their cancer diagnosis (Tavoli, 2007).

Mental and emotional well-being depends very much upon the issues regarding culture and the manner

in which information is communicated to sufferers of malignancy (Chowdhury, 2011).

Regardless of the type or phase of cancer, it may be important to recognize and manage somatic

symptoms in order to achieve improved quality of life and functioning (Kroenke, 2010).

Patients detected to have an anxiety disorder were more expected to be of female gender, of lesser age,

and have a poorer status of physical performance (Spencer, 2010).

Those patients with a past history of alcohol abuse/dependence or mood disorder, later stages of

malignancy, pain under poor control, and therapy using drugs or concurrent diseases that cause depression are at

utmost risk of developing depressive disorder (Massie, 1990).

The chances of elevated scores of the Center for Epidemiologic Studies-Depression Scale (CES-D)

were notably decreased in patients aged more than 50 years in comparison with those whose age was less than

or equal to 50 years. The score was also lesser in patients with greater levels of social support and in patients in

employment. Men were more to be expected to have depressive disorder indicated by higher CES-D scores.

Awareness of sociodemographic features will help the physician to identify those persons who have an

increased risk of associated depressive symptomatology (Reisine, 2005).

Nearly 33% of long-term survivors of malignancy (5 years +) go on to harbour fears of recurrence,

fears of developing yet another malignancy, and fears that some of their symptoms may be due to malignancy.

Health anxieties related to malignancy are an important predictor of both anxiety and depression. The largely

unfailing predictor of mental anguish is optimistic/pessimistic disposition, with lesser malignancy-associated

health anxieties, and lesser depression and anxiety, in persons with dispositional optimism. All said and done,

for most of them, physical or psychological quality of life is not radically compromised (Deimling, 2006).

Quality of life is predicted by 4 major variables: contentment with support of family doctor,

malignancy severity, sufferer’s gender, and malignancy type. Mental state was predicted by 3 main factors:

anorexia, support of family doctor, sufferer’s gender (Mathieson, 1996).

HADS depression score was significantly correlated with fatigue, nausea, sleep disturbances, distress,

and memory, loss of appetite, drowsiness, dry mouth and sadness (Arun, 2011).

In one study, long term survivors of NSCLC were studied regarding their quality of life. It was found

that hopeful survivors formed the majority (71%), and the experience of malignancy was seen as leading to

constructive existential changes by 50% of the survivors. Sixty percent had more than one condition showing

that co-morbidity was frequent; a CES-D score of more than 16 was found in 22% indicating distressed mood.

76% had been smoking previously. A prospective target for intervention is comprised of the predictors of poorer

quality of life which are robustly related to distressed mood (Sarna, 2002).

Among non-small cell lung cancer (NSCLC) and small cell lung cancer (SCLC) sufferers, sufferers

with SCLC had thrice higher frequency of depressive disorder than those with NSCLC. The most vital risk

factor was impairment of function; for every increase on the functional impairment score, depressive symptoms

rose by 41 percent. Major independent predictors were load of somatic symptoms prior to treatment, fatigue and

performance status rated by physician. Histological subtype was not an independent predictor (Hopwood, 2000).

The most depressed and anxious sufferers of lung malignancy are those who have repeated and long

duration waking periods at night and repeated and long duration sedentary periods during day. The anxiety

and/or depression scores are directly proportional to the severity of disruption of the circadian rhythm (Du-

Quiton, 2010).

Depressive disorder was linked to female sex and performance status being low. 1/3rd

of sufferers of

newly detected non-small cell lung cancer had anxiety and depression. This was linked to reduced score on

health-related quality of life questionnaires, and compliance to therapy and bad prognosis were independently

linked to depression (Arrieta, 2013).

Depressive disorder is frequent and persistent in sufferers of pulmonary malignancy, more so in those

with more relentless symptoms or limitation of function. Therefore, palliation must include the crucial element

of screening for psychological problems and managing them appropriately.

Role of personality and coping styles

More cognitive distortions and maladaptive assumptions were present in the group with

depressive symptomatology. The prime coping mechanism which was employed by subjects in the group



without depressive symptomatology was fighting spirit, while the mechanisms used to cope in the group with

depressive symptomatology were hopelessness/helplessness, being preoccupied / being worried and fatalistic

coping style (Alcalar, 2012).

Existing research suggests that malignancy sufferers’ adjustment may be constructively impacted upon

by coping through spiritual and religious means (Jenkins, 1995).

It is important to survey the patients' personalities in order to grasp their QOL accurately (Nakada,

1996).

Mental factors which have strong association with increased depressive risk are personality

characteristics like neuroticism, and coping approaches such as anxious preoccupation, hopelessness /

helplessness and low fighting spirit. Depressive symptomatology was robustly associated with temperamental

traits and mechanisms employed to cope, and employing tools for screening to recognise these variables might

be helpful for planning preventive (Shimizu, 2012).

Effect of cancer stigma

Sufferers who felt or experienced the stigma of malignancy were 2.5 times more expected to have

depressive disorder than sufferers with optimistic disposition. In spite of quantum leaps made in the field of

medicine and greater survival rates, malignancy survivors still felt stigmas about malignancy, and it was notably

linked to depressive symptomatology. These results stress upon the requirement for the medical fraternity and

health care providers to give more notice to stigma about malignancy which sufferers may be expected to face

during therapy (Cho, 2013).

Anxiety and depression screening in malignancy

Many studies till date which have examined the existence of anxiety and depression in

sufferers of malignancy have used the Hospital Anxiety and Depression Scale (HADS) (Moorey, 1991; Kugaya,

2000). The HADS is an easy to administer, self-rated instrument and is efficient in screening for depressive and

anxious symptomatology, even in early stages of malignancy (Berard, 2001). It has been found that the HADS,

along with the Impact of Event Scale’s intrusion subscale, can be useful to detect chances of tardy development

of depressive and anxious symptomatology in sufferers of malignancy (Nordin, 1999).

Yet another screening instrument found to be adequate for use in patients with cancer is the Beck

Depression Inventory -II (BDI-II) (Warmenhoven, 2011)

Prediction of depression and anxiety following detection of malignancy

An investigation was done to inspect the likelihood of predicting depressive and anxiety

disorders 6 months after detection of malignancy, based on scores of depressive and anxious symptomatology,

mechanisms employed to cope and subjective anguish associated with the detection of cancer. Patient anxiety

and depression close to the detection explained nearly 35% of the variation in depression and anxiety symptoms

seen after 6 months. For finding out sufferers who are likely to develop tardy depression and anxiety, the Impact

of Events Scale- Intrusion Subscale and the Hospital Anxiety and Depression Scale may be useful tools (Nordin,

1999).

Yet another study found that age less than 65 years, being employed or not, family support, and several

symptoms due to malignancy or treatment independently predicted depressive disorder (Agarwal, 2010).

Gender, race, co-morbid conditions, physical functioning, social functioning, and symptoms were

important predictors of depression. Both greater number of symptoms and greater limitation of functional

performance in somatic and social domains were associated with increase in symptoms of depression (Kurtz,

2002).

Functional performance in the emotional domain is a vital predictor of the need for social support.

Women are emotionally more affected than men and need more psychosocial support (Ernstmann, 2009).

More severe symptoms of depression, being of young age and being single- all these increase the

chances for sufferers of metastatic malignancy of being referred for psychosocial supportive care

(Ellis, 2009).

Feminine sex was linked to the existence of depressive and anxious symptomatology. Lesser tumour

grade on the WHO classification of grade of malignancy, academic accomplishment being lower, and past

history of mental disorder were significant predictors of depressive and anxious symptomatology. Depressive

disorder alone was significantly linked to relationship status and history of current/past physical disease

(Arnold, 2008).

Effects of cancer on depression

Epidermal Growth Factor Receptor mutations were linked to reduced severity of depressive

disorder and decreased probabilities of depression in sufferers of non-small cell lung cancer in metastatic stage.



This was found out on the basis of screening for affective symptoms done prior to obtaining the genotyping

findings (Pirl, 2011).

Affective disorders are promoted by the physiologic substrate afforded by inflammation (Raison &

Miller, 2003). Features of cytokine induced sickness syndrome in cancer include fatigue, loss of appetite &

weight, cognitive disturbances, decreased motor activity and libido.

Links among state of nutrition, systemic inflammation, and subjective mental suffering are evidence of

their shared fundamental pathophysiology and go on to impress upon the need for an anti-cachectic approach

which is holistic (Giannousi, 2012).

Effects of chemotherapy

In a study, 13.7% patients who were undergoing chemotherapy experienced depression. Important

predictors were education level and symptoms like pain, insomnia, nausea, anorexia and fatigue (Akechi, 2012).

Chemotherapy is associated with many adverse effects which negatively affect the quality of life of

sufferers of malignancy of the breast. Similar is the case with adjuvant hormonal therapies (Montazeri, 2008).

In a study among patients undergoing chemotherapy, anxiety was found in about 15% and depression

in about 16% subjects. They found that high social status influenced presence of distress and female gender

influenced the prevalence of depression (Pandey, 2006).

The anxiety state is significantly higher in patients treated with cytotoxic drugs than in operated and

increased during the time of treatment. In patients treated with cytotoxic drugs, anxiety as a feature, increased in

the course of treatment, and in patients treated surgically it remained stable (Nalepa, 1996).

Li and colleagues (2012) found in their study that during chemotherapy, the patients had significant

anxiety.

Effects of radiotherapy

Psychological distress was found to be highly prevalent (30% of cases) in persons receiving

radiotherapy for malignancy of the head and neck (Bjordal, 1995) This is true even before beginning treatment

and it increases significantly during treatment (Chen, 2009).

In another study, 33% of patients who had completed a course of radiotherapy had depression (Lloyd-

Williams, 1994).

Patients' views about radiotherapy: Most patients believed that radiation is inherently damaging and

carcinogenic. They thought that it was bad news if they required radiotherapy. It was seen as curative by few.

Post treatment interviews showed more depression and anxiety than pre treatment interviews. This meant that

the procedure was a stressful one. However, it is ironic that the concepts of very serious adverse effects and

futility of this treatment among both doctors and lay people are largely false (Peck and Boland, 1972).

A study looked for anxiety and depression in patients with prostate or other urogenital cancers. Higher

psychological distress was found in those were receiving radiotherapy (Hinz, 2009).

IV. Aim And Hypothesis Objectives

Primary objective- To find the prevalence of depression and anxiety in lung cancer patients

in a tertiary hospital inpatient population.

Secondary Objective(s)-

1. To find the risk factors for depression and anxiety in lung cancer patients.

2. To determine the extent to which depression and anxiety can be predicted on the basis of measures of

subjective distress and social support.

V. Materials And Methods Study centre

We recruited the participants for the study from the inpatients admitted in the Dept. of

Medical Oncology, Rajiv Gandhi Govt. General Hospital, Chennai.

All the study participants were of different stages of lung cancer who were planned for

chemotherapy or already undergoing it.

Patient selection

We interviewed the patients by the bedside during their inpatient admission. We informed

them about the nature of the assessment- to elicit psychological distress- being done as a part of a research study

and obtained their informed consent to proceed with the assessment.



Inclusion criteria

All patients diagnosed with lung cancer irrespective of stage or grade

Exclusion criteria

a. Patients not willing to participate

b. Patients already diagnosed as having any mental illness before the onset of cancer

c. Patients who were not physically fit enough to complete the study

d. Patients with severe cognitive impairment screened by MMSE

Screening

We used the Hospital Anxiety and Depression Scale (HADS) to screen the presence of anxiety and/or

depression. A score of 8 or above on the anxiety and/or depression subscales denoted case status.

Sample size

We conducted the data collection over a period of three months. The sample size was 93.

Assessment of patients

We made two types of assessments:

1. For those scoring 8 or more on the HADS subscales, all the questionnaires mentioned below were

administered.

2. For those scoring less than 8 on the HADS subscales, all the questionnaires mentioned below were

administered, except for the Hamilton Depression Rating Scale (HAM-D/HDRS) and the Hamilton Anxiety

Rating Scale (HAM-A).

Sociodemographic data

We recorded the patients’ socio-demographic variables and illness variables on a proforma

specially designed for the study (Appendix I).

Phase of illness

Phase of illness was classified as: phase 1—newly diagnosed persons, phase 2—persons in

first remission, phase 3—persons following the development of a second primary lesion without metastasis, and

phase 4—persons with metastatic disease (Agarwal, 2010).

Instruments

1. Karnofsky Performance Status Scale (KPS) - The Karnofsky Performance Status (KPS) is a widely used

method to assess the functional status of a patient. It was introduced by David A. Karnofsky and Joseph H.

Burchenal in 1949. Originally entitled Performance Status, the term Karnofsky Performance Status was

coined at a later date, and renamed after the author of its creation. It is a standard way of measuring the

ability of cancer patients to perform ordinary tasks. The Karnofsky score runs from 100 to 0, where 100 is

"perfect" health and 0 is death. KPS may be used to determine a patient's prognosis, to measure changes in

a patient’s ability to function, or to decide if a patient could be included in a clinical trial. (Karnofsky, 1949)

2. Fagerstrom Test for Nicotine Dependence – It is a revision of the Fagerström Tolerance Questionnaire

(FTQ; Fagerström, 1978). It has 6 items which includes items like time to first cigarette of the day, smoking

in forbidden places and number of cigarettes smoked per day, etc., Scoring: 0-2: very low dependence

3-4: low dependence

5: medium dependence

6-7: high dependence

8-10: very high dependence

(Heatherton, 1991)

3. Hospital Anxiety and Depression Scale (HADS) - Originally developed by Zigmond and Snaith in 1983

as a tool for the detection of anxiety and depression in people with physical health problems. It is a fourteen

item scale. Seven of the items relate to anxiety and seven relate to depression. Each item on the

questionnaire is scored from 0-3 and this means that a person can score between 0 and 21 for either anxiety

or depression. The scale used is a Likert scale and therefore the data returned from the HADS is ordinal.

(Zigmond, 1983)

4. Hamilton Depression Rating Scale (HAM-D/HDRS) – It was developed by Hamilton in 1960 to monitor

the severity of major depression. The ratings can be completed in 15 to 20 minutes. Reliability is good to

excellent, including internal consistency and inter-rater assessments. Validity appears good based on

correlation with other depression symptom measures.

Scoring:- 7 or less: normal

8-13: mild



14-18: moderate

19-22: severe

23 and above: very severe

(Hamilton, 1960)

5. Hamilton Anxiety Rating Scale (HAM-A): A psychological questionnaire used by clinicians to rate the

severity of a patient's anxiety. It was originally published by Max Hamilton in 1959. It contains

14 symptom-oriented questions. Each of these symptoms is given a severity rating, from not present (scored

as 0) to very severe (scored as 4). The clinician must choose the possible responses to each question by

interviewing the patient and by observing the patient's symptoms. Administration time is about 10-20

minutes. Each question is scored 0-4. A total score of 0-17 is considered to be mild, 18-25 mild to

moderate, and 26-30 moderate to severe. Totals above 30 are rare, but indicate very severe anxiety

(Hamilton, 1959).

6. Social Support Questionnaire – It was developed by Sarason et al. in 1983. It measures the perceived

social support in individuals. The short form has six items. Each item has two parts. The first part assesses

the number of available others the individual feels he/she can turn to in times of need in each of a variety of

situations and gives the Number or Perceived Availability Score. The second part measures the individual’s

degree of satisfaction with the perceived support available in that particular situation (Sarason, 1987).

7. Presumptive Stressful Life Events Scale (PSLES) – It was introduced by Gurmeet Singh in 1984. It is the

Indian adaptation of the Holmes and Rahe Stress Scale validated and standardized for our population. It

consists of 51 stressful life events classified as desirable, undesirable, ambiguous, personal and impersonal.

(Singh, 1984)

8. WHOQOL-BREF (World Health Organization Quality of Life – BREF) – I t is a scale for measuring

the quality of life. It has 4 domains- physical health, psychological health, social relationships and

environment. (WHO, 2004)

9. Sheehan Disability Scale (SDS) – It is a self-report scale which assesses functional impairment in three

interrelated domains- work/school, social and family life. It is a 10-point visual analog scale. The total of

the three domains gives the global functional impairment measure that ranges from 0 (unimpaired) to 30

(highly impaired) (Sheehan, 1996). In patients suffering from cancer, the impact of somatic symptom

burden on disability and healthcare use can be quantified by using the Sheehan Disability Scale (SDS). This

is important because somatic symptoms have to be recognized and managed in order to improve quality of

life and functional status of these patients (Kroenke et al, 2010).

10. Satisfaction with Life Scale (SLS) – It was introduced by Ed Diener. It is a short 5-item instrument

designed to measure global cognitive judgments of satisfaction with one's life. Each item is rated from 1-7.

(Diener, 1985)

Data analysis and Statistics

Data analysis was done using the SPSS software version 20.

Statistical tests employed were-

1. Chi-square test

2. Independent sample t-test

3. Pearson’s correlation

4. One way analysis of variance (ANOVA)

VI. Results Ninety three consecutive cases were included in the study to assess the prevalence of depressive and

anxiety symptoms in the group of inpatients admitted in the Medical Oncology Department, Rajiv Gandhi

Government General Hospital, Chennai for non-small cell lung cancers (NSCLCs) of various stages.

The breakup of the sample consisted of 43 patients diagnosed as cases when the cut-off score of HADS

more than or equal to 8 was taken. A total of 93 patients were screened to obtain this sample with the rest 50

being controls.

Those scoring just below the cut-off score of 8 were further evaluated for the presence of depression

and/or anxiety using the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID). Of that group of 50

patients none was found to fulfil the criteria for a diagnosis of depression and/or anxiety. This was done so as

not to miss out any cases screened by the HADS.

Sample demographics

The demographic profiles of the sample are given below:



Table 1: Gender

Sex

Group Total

Control Case N %

N % N %

Men 38 76.0 29 67.4 67 72.0

Women 12 24.0 14 32.6 26 28.0

Total 50 100.0 43 100.0 93 100.0

Chi-Square Test P-Value

Pearson Chi-Square 0.359

Men comprised 72% of the sample while 28% were women. The gender distribution did not

differ significantly between the case and control groups.

Chart 1

The two groups did not differ significantly in gender distribution.

Table 2: Age Mean 52.72

Median 52.00

Mode 55

Std. Deviation 12.024

The mean age of the sample was 52.72 years with a standard deviation of 12.024 years.

Chart 2: Age distribution

The median age of the sample was 52 years and the age distribution followed normal distribution.



Table 3: Age comparison between the groups

N Valid 43

Missing 0

Mean 52.23

Median 53.00

Mode 64


Cases

The two groups did not differ significantly in age distribution.

Chart 3: Age distribution among cases and controls

Controls The two groups did not differ significantly in age distribution.

Cases

Table 4: Residence

Address

Group Total

Control Case N %

N % N %

Rural 23 46.0 22 51.2 45 48.4

Semi urban 9 18.0 9 20.9 18 19.4

Urban 18 36.0 12 27.9 30 32.3

Total 50 100.0 43 100.0 93 100.0

N Valid 49

Missing 0

Mean 53.24

Median 52.00

Mode 55


Controls





Case and control group did not differ significantly in terms of place of residence.

Chart 4:

Most of the subjects in both the groups resided in rural areas.

Table 5: Education

Education

Group Total

Control Case N %

N % N %

Illiterate 16 32.0 15 34.9 31 33.3

Primary school 9 18.0 9 20.9 18 19.4

Middle school 15 30.0 10 23.3 25 26.9

High school 10 20.0 9 20.9 19 20.4

Total 50 100.0 43 100.0 93 100.0



Case and control group did not differ significantly in terms of educational qualification.

Chart 5:

Most of the subjects in both groups had never attended school.



Table 6: Occupation

Occupation

Group Total

Control Case N %

N % N %

Unemployed 9 18.0 5 11.6 14 15.1

Unskilled worker 15 30.0 10 23.3 25 26.9

Semiskilled worker 1 2.0 6 14.0 7 7.5

Skilled worker 6 12.0 9 20.9 15 16.1

Clerical, shop-owner, farmer 15 30.0 10 23.3 25 26.9

Semi-profession 4 8.0 3 7.0 7 7.5

Total 50 100.0 43 100.0 93 100.0


Fisher's Exact Test 0.233

No significant difference was found between the two groups in terms of occupation.

Chart 6: Occupation

Controls

Unskilled work was the most common occupation in both groups.

Cases

1=unemployed, 2=unskilled worker, 3=semiskilled worker, 4= skilled worker, 5= clerical, shop-owner, farmer,

6= semi-profession, 7= profession



Table 7: Marital status

Marital status

Group Total

Control Case N %

N % N %

Single 7 14.0 4 9.3 11 11.8

Married 37 74.0 28 65.1 65 69.9

Separated 1 2.0 7 16.3 8 8.6

Widowed 5 10.0 4 9.3 9 9.7

Total 50 100.0 43 100.0 93 100.0



The two groups did not differ significantly in terms of marital status.

Chart 7:

Most of the subjects in both the groups were married.

Table 8: Family type

Family type

Group Total

Control Case N %

N % N %

Staying alone 1 2.0 4 9.3 5 5.4

Nuclear 21 42.0 22 51.2 43 46.2

Extended 9 18.0 7 16.3 16 17.2

Joint 19 38.0 10 23.3 29 31.2

Total 50 100.0 43 100.0 93 100.0



The two groups did not differ significantly in terms of family type.



Chart 8: Family type

Controls

Cases

1=staying alone, 2=nuclear, 3=extended, 4=joint, Nuclear family was most common in both

case and control groups.

Table 9: Language

Language

Group Total

Control Case N %

N % N %

Tamil 42 84.0 33 76.7 75 80.6

Telugu 4 8.0 4 9.3 8 8.6

Urdu 2 4.0 4 9.3 6 6.5

Malayalam 1 2.0 2 4.7 3 3.2

Nepali 1 2.0 0 .0 1 1.1

Total 50 100.0 43 100.0 93 100.0



The two groups did not differ significantly in terms of language distribution



Chart 9: Language

Controls 1=tamil, 2=telugu, 3=urdu, 4=malayalam, 5=nepali

Tamil was the most common language spoken in both groups.

Cases

Table 10: Religion

Religion

Group Total

Control Case N %

N % N %

Hindu 47 94.0 35 81.4 82 88.2

Islam 2 4.0 4 9.3 6 6.5

Christian 1 2.0 4 9.3 5 5.4

Total 50 100.0 43 100.0 93 100.0



The two groups did not differ significantly in terms of religion.



Chart 10: Religion

Controls

1=Hinduism, 2=Islam, 3=Christianity

Hinduism was the most common religion practised among both groups.

Cases

Table 11: Mean time since diagnosis

The mean time since diagnosis in the control group was 24 months whereas in the case group it was 16

months.

Table 12:

Phase of illness (1-4)

Group Total

Control Case N %

N % N %

Phase-1 17 34.0 14 32.6 31 33.3

Phase-2 18 36.0 11 25.6 29 31.2

Phase-3 6 12.0 4 9.3 10 10.8

Phase-4 9 18.0 14 32.6 23 24.7

Total 50 100.0 43 100.0 93 100.0



There was no significant difference between the two groups in terms of phase of illness.

Controls 24 months

Cases 16 months



Chart 11:

Most of the subjects in the case group were in phase 4 whereas most in the control group were in phase

2 of illness.

Independent samples T-Test to compare the mean value between groups

Table 13: Group N Mean Std. Deviation P-Value

Age Control 50 53.14 11.225

0.719 Case 43 52.23 13.009

Time since diagnosis (months) Control 50 23.58 30.470

0.201 Case 43 16.26 23.199

Karnofsky Performance Status Score

(0-100)

Control 50 70.80 11.400 0.883

Case 43 70.47 10.225

FTND Control 50 4.36 3.729

0.579 Case 43 3.93 3.686

HADS Anxiety Score Control 50 1.48 2.197

<0.001 Case 43 11.07 4.426

HADS Depression Score Control 50 2.16 2.444

<0.001 Case 43 12.65 4.105

HAM-D Control 50 .00 .000

<0.001 Case 43 23.77 10.982

HAM-A Control 50 .00 .000

<0.001 Case 43 21.58 13.713

SSQ Number Control 50 3.9368 2.95457

0.301 Case 43 3.3433 2.55312

SSQ Satisfaction Control 50 4.4362 1.55612

0.980 Case 43 4.4271 1.88575

Presumptive Stressful Life Events

Score

Control 50 91.10 44.140 0.031

Case 43 110.28 39.472

Total WHOQOL-BREF Control 50 73.92 17.145

0.001 Case 43 96.79 37.977

Sheehan Disability Score (0-30) Control 50 25.18 33.354

0.006 Case 43 53.07 55.941

Satisfaction With Life Score Control 50 67.38 57.172

0.571 Case 43 78.23 112.964

Statistically significant difference was found between the case and control groups with respect to the

following variables:

1. HADS Anxiety score

2. HADS Depression score

3. HAM-D score



4. HAM-A score

5. Presumptive stressful life events score

6. Total WHOQOL-BREF

7. Sheehan disability score

Table 14: Nicotine dependence

FTND Dependence

Group Total

Control Case N %

N % N %

Very low 20 40.0 19 44.2 39 41.9

Low 1 2.0 2 4.7 3 3.2

Medium 1 2.0 1 2.3 2 2.2

High 15 30.0 11 25.6 26 28.0

Very high 13 26.0 10 23.3 23 24.7

Total 50 100.0 43 100.0 93 100.0



The two groups did not differ significantly with respect to nicotine dependence.

Chart 12:

Nicotine dependence pattern was similar between the case and control groups.

Chart 13:

The two groups did not differ significantly in terms of Karnofsky performance status score.



Chart 14:

The Mean HADS Anxiety Score was significantly higher in the case group compared to the control group.

Chart 15:

The Mean HADS Depression Score was significantly high in the case group compared to the

control group.

Chart 16: Frequency of anxiety and depression in the study sample based on screening with HADS score

Anxiety

Anxiety (HADS Anxiety Score > 8) was present in 35% of the subjects.



Depression

Depression (HADS Depression Score > 8) was present in 41% of the subjects.

Table 15: HAM-A score HAMA Level Group Total

Control Case N %

N % N %

Mild 50 100.0 18 41.9 68 73.1

Moderate 0 .0 7 16.3 7 7.5

Severe 0 .0 5 11.6 5 5.4

Very severe 0 .0 13 30.2 13 14.0

Total 50 100.0 43 100.0 93 100.0


Fisher's Exact Test <0.001

There was significant difference between the two groups in terms of HAM-A score. Mild

anxiety was most common (41.9%) followed by very severe anxiety (30.2%) in the case group.

Chart 17:

The mean HAM-A score in the case group was 21.6

55, 59%

38, 41% No depression

Depression



Table 16: HAM-D score HAMD Level Group Total

Control Case N %

N % N %

Normal 50 100.0 4 9.3 54 58.1

Mild 0 .0 3 7.0 3 3.2

Moderate 0 .0 6 14.0 6 6.5

Severe 0 .0 3 7.0 3 3.2

Very severe 0 .0 27 62.8 27 29.0

Total 50 100.0 43 100.0 93 100.0


Fisher's Exact Test <0.001

There was significant difference between the two groups in terms of HAM-D score. Very

severe depression was most common (62.8%) followed by moderate depression (14%) in the case group

Chart 18:

The mean HAM-D score in the case group was 23.8

Chart 19: Social Support Questionnaire scores



The two groups did not differ significantly in terms of both Number and Satisfaction subscales of the Social

Support Questionnaire.

Chart 20:

Significantly higher stressful life events scores were observed in the case group compared to

the control group.

Chart 21:

Significantly higher Total WHOQOL-BREF scores were observed in the case group compared

to the control group.



VII. Discussion The objective of the study was to evaluate the association of certain sociodemographic and

illness related factors with depression and anxiety in a group of patients with lung cancer. The factors to be

studied were selected after reviewing earlier studies which indicated some variables to be more frequently

linked to psychological distress in patients with cancer. These factors have been summarized by Holland (1993).

Selection of the sample population for the study

The factors gender, age and phase of illness were all considered as variables in the study.

Because cancer is a heterogenous condition we did not want to study all cancers, keeping type of cancer as a

variable. This was so decided because the findings in one type of cancer can’t be generalized to all other types

of malignancy. Hence we decided to confine our study to the prevalence and predictors of depression and

anxiety in patients with non-small cell lung cancer. This group of 93 consisted of the patients consecutively

admitted in the Medical Oncology ward in Rajiv Gandhi Government General Hospital, Chennai during the

specified period and more sample size couldn’t be collected due to time constraint.

The patients were seen in a tertiary referral hospital setup. Most of them had been referred

there with long duration of illness, after failed attempts at treatment or for more advanced therapy.

Prevalence of depression and anxiety

With respect to anxiety, 33 subjects (i.e. 35%) scored above 8 in HADS Anxiety subscale and

hence were considered as cases. False negatives among the remaining 60 controls (i.e. 65%) were avoided by

subjecting them to clinical interview using the SCID. The prevalence rate of 35% in the study is on the higher

side compared to previous studies. Akechi et al (2001) found the prevalence of anxiety to be 18% in their study.

Mendonsa and Appaya (2010) found the figure of 17%.

With respect to depression, 38 subjects (i.e. 41%) scored above 8 in HADS Depression

subscale and hence were considered as cases. False negatives among the remaining 55 controls (i.e. 59%) were

avoided by subjecting them to clinical interview using the SCID. The prevalence rate of 41% in the study is on

the higher side compared to previous studies. Bukberg et al (1994) had found in their study 24% prevalence of

severe depression and 18% prevalence of moderate depression. Hegel et al (2006) found depression in 11% of

their study subjects. Akechi et al (2001) reported a figure of 14% in their study. Kugaya et al (2000) found out a

prevalence of 17% in their study subjects. Massie MJ (1990) reported 25% prevalence in hospital admitted

patients with cancer. Mendonsa and Appaya (2010) found out 26% frequency of depression in their study. A

prevalence of 14% was reported in an outpatient oncology clinic by Berard et al (1998). Many other previous

studies on the prevalence of depression in lung cancer have placed the figure anywhere in the range of 11-44%

(Massie, 2004).

The high prevalence of anxiety and depression in this study could be due to the following

reasons:

1. The criteria used included mild, moderate and severe forms of anxiety and depression.

2. Many of the subjects had recurrence after successful treatment. Recurrence has higher prevalence of

depression compared to the primary therapy of terminal stage groups (Silberfarb, 1980). Thus, it is evident

that many high risk factors for depression and anxiety being inherent in the chosen sample could have led to

the high prevalence rate.

3. The criteria didn’t exclude somatic symptoms in the patients which was very high as found in the study.

4. The reactive element (? Adjustment disorder) couldn’t be ruled out.

Illness related variables

The present study found an increased frequency of the most common symptoms seen in

cancer patients i.e. anorexia, fatigue, sleep disturbance, in patients who had scored above the cut-off for being

designated as cases. Although this could be expected because it could have been contributed by either

depression or cancer or both, it is also possible that persons with underlying dysphoric mood may perceive more

somatic symptoms (Endicott, 1984). The study also revealed that phase of illness has a bearing upon being

depressed or anxious. It has revealed that the advanced phase 4, with its attendant complications was

significantly associated with depression and anxiety. This could probably be due to the fact that there is more

physical disability in this phase compared to the phases 1 and 2.

Time since diagnosis

Mean time since diagnosis was found in our study to be 16 months in the case group

compared to 24 months in the control group. Probably, the additional symptom burden of depression

and/anxiety affected response to treatment and hence referral to tertiary care at an earlier time in these patients.



Presumptive stressful life events score

The presumptive stressful life events score was significantly higher in cases compared to controls. This

could be due to additional life stressors resulting secondarily due to the cancer or its diagnosis, for eg., loss of

job.

Total WHOQOL-BREF score

The quality of life score was actually significantly higher in our study in the case group compared with

the control group. This is an unexpected finding and we are unable to find an explanation for this.

Sheehan Disability score

The disability score was significantly higher in the cases compared to the controls. This is probably due

to the fact that most subjects in the case group were in advanced phase of cancer (phase 4) and this led to more

physical complications which in turn led to more disability.

LIMITATIONS

1. Small sample size.

2. Cross-sectional study design- This limited the chances of predicting future possibility of depression and

anxiety based on current anxiety and depression scale scores.

3. Overlap of somatic symptoms of cancer with those of depression.

4. Personality factors were not taken into account as a variable mediating anxiety and/or depression in these

patients.

5. Coping through religious beliefs, which is thought to be universally important (Jenkins, 1995), was not

assessed systematically.

6. Cognitive impairment was not assessed with measures rigorous enough to determine its influence on

depression and/or anxiety.

VIII. Suggestions Interventions in cancer patients

1. Detection of depression and/or anxiety by the cancer care team

The study shows certain factors like recurrence of symptoms and functional status to be associated with

increased risk for depression and/or anxiety in cancer patients. Increasing the sensitivity of health personnel

caring for these patients to these factors could lead to earlier interventions.

The HADS is found to be a useful instrument for screening purpose. The measurement is simple and

can be easily administered by non-mental health personnel. It could thus be used routinely to screen patients in

this high risk group.

The sensitivity among the professionals in palliative care centres and pain clinics to detect

depression/anxiety and institute appropriate management or referral needs to be increased.

2. Patient education and providing information to caregivers

The meaning which the patient attributes to his symptoms could alter his perceptions about the nature

of the illness and lead to psychological distress. Hence, explaining the origin of symptoms, its meaning and

correlation with disease status would alleviate distress to a great extent. This pattern of explanation should

become routine with all patients.

3. Training the treating team in psychosocial management

Specific psychotherapeutic skills of listening, providing psychological support, group work, talking

about death, etc., should be provided through practical training programs like workshops.

Future Directions

1. The study has demonstrated the relationship between depression/anxiety and various other factors like

physical disability, phase of cancer, etc., Studies in future need to assess each of these factors in depth.

2. Longitudinal studies (cohort and case-control) following patients from date of initial presentation are

needed.

3. Studies are needed to clarify whether tendencies toward having negative cognitive distortions predispose

patients with cancer to develop depression. This may help in planning interventions based on cognitive-

behavioral models.

4. The spiritual domain of coping which is an important coping strategy has to be assessed after developing

scales that are applicable to the Indian social situation.



5. More than self-report scales, in-depth interviews, case studies and other qualitative methods of research

would be valuable in exploring concepts and processes which are part of this domain.

6. There is a dearth of studies on depression and/anxiety in lung cancer patients which needs to be addressed

in the future.

IX. Conclusion 1. The prevalence of depression and anxiety in lung cancer patients in this tertiary hospital inpatient

population was found to be 41% and 35% respectively.

2. The major risk factors for depression and anxiety in lung cancer patients as found in the study were

presence of concomitant life stressors, advanced cancer phase and higher disability.

3. The observation of the association of some factors other than the illness requires interventions of

psychosocial nature with all patients. Specifically, there is need to explore the personal meaning of cancer

symptoms, of terminality, death and dependency from the individual and socio-cultural context of

sufferers of malignancy. Efforts must be made to provide this help along with medical care to all patients.

This necessitates close liaison between the fields of Psychiatry and Oncology leading to the flowering of

the branch of Psycho-oncology.

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Gayathri Narayanasamy - IOSR Journals 9/Version-2...Gayathri Narayanasamy I. Introduction Psychiatric oncology is the field of medicine concerned with frequent mental and affective